Māori Medical Student and Physician Exposure to Racism, Discrimination, Harassment, and Bullying

Key Points Question What is the prevalence of exposure to racism, discrimination, bullying, and harassment for Māori medical students and physicians in New Zealand and does it vary by medical student and physician characteristics? Findings In this cross-sectional national survey of 405 Māori physicians and Māori medical students, direct and witnessed racism, discrimination, bullying, and harassment experiences were common, with some associations with gender, marginalized status, age for medical students and seniority for physicians. Meaning These findings suggest that medical education and workplaces should address the high reported experience of multiple forms of racism, discrimination, bullying, and harassment for Māori medical students and physicians.


Introduction
[20][21][22] For Māori medical students and physicians in New Zealand, as for Indigenous medical professionals internationally, exposures to racism, discrimination, bullying, and harassment in medicine are intertwined with exposures to racism and other systems of oppression in society more generally.6][27] Thus, how these are experienced for Māori students and physicians relative to other medical students and physicians may be qualitatively different. 27 part of the Te Whakahaumaru Taiao project on safe environments for Māori medical practitioners, 28 national surveys were carried out in New Zealand to assess prevalence of racism, discrimination, bullying, and harassment in medical education, training, and workplaces and to explore impacts on health and careers for Māori medical students and physicians.This study reports findings on the prevalence of racism, other forms of discrimination, bullying, and harassment and associations of these with Māori medical student and physician characteristics.

Methods
This cross-sectional study using survey data was approved by the Auckland Health Research Ethics Committee.Informed consent was provided by all participants electronically at the beginning of the survey.We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
Data were collected via voluntary anonymous national-level online surveys (Qualtrics).All physicians and medical students identifying as Māori were invited to take part.Eligible participants were medical students enrolled in 2021 in years 2 through 6 at either of New Zealand's 2 medical schools (University of Auckland and University of Otago) and all physicians with a current annual practicing certificate from the Medical Council of New Zealand.Further information on the New Zealand context is provided in eAppendix 1 in Supplement 1. Due to some inconsistency in reporting across the different institutions, we took the highest reported number of Māori medical students (491 students) 29 and physicians (854 physicians) as response rate denominators to produce the most conservative estimate.
Invitations were sent to students by administrators and to physicians by Te Ohu Rata o Aotearoa (Māori Medical Practitioners Association), Medical Council of New Zealand, medical colleges, unions, academic institutions, and personal networks.The survey was also advertised on social media and the project website.Initial invitations were followed by reminder emails and additional advertising.

Measures
Survey development was informed by literature reviews, interviews with Māori medical students, and expert advisory input.As this was the first survey of its kind, it included both existing tools (some adapted) and new measures, reviewed by independent experts.Separate versions were prepared for medical students and physicians, with common questions and questions specific to each group (eAppendix 2 in Supplement 1).

Racism, Discrimination, Bullying, and Harassment
Participants were asked if they had directly experienced or witnessed (seen, heard, or heard about) another person or a group of people being subjected to discrimination, racism, bullying, or harassment, with definitions for each concept provided before the question (eAppendix 2 in Supplement 1).Students were asked about exposures during medical education and training, and physicians about exposures in the workplace and during work-related activities.Response options were "Yes, within the last 12 months"; "Yes, more than 12 months ago"; "No, never"; and "Don't know." Participants were able to select yes for both timeframes where applicable.
Experience of each of the 4 exposures (direct or witnessed) was recorded for the last 12 months.
For analysis, an ever exposure category combined responses "Yes, within the last 12 months" and "Yes, more than 12 months ago."We also created composite variables for any direct experience of racism, discrimination, bullying, or harassment (last 12 months, ever) and any witnessed racism, discrimination, bullying, or harassment (last 12 months, ever) and 8 variables for any direct or witnessed racism, discrimination, bullying, or harassment in the last 12 months and any direct or witnessed racism, discrimination, bullying, or harassment ever.

Stereotypes
We asked whether participants had seen or heard their colleagues or people in leadership roles make negative comments or jokes about several specific groups of people, including comments to or about patients, colleagues, or students.The groups of people asked about were those with a higher body mass index, lower socioeconomic status, of Māori ethnicity, of non-European ethnicity other than Māori (eg, Asian, Pacific), with lower levels of education, with disabilities, women, and/or people who are lesbian, gay, bisexual, transgender, queer, intersex, asexual, and others (LGBTQIA+); Rainbow; or Takatāpui.Response options were yes, no, and do not know.

Discriminatory Treatment
Students in the clinical years of their program (years 4-6) and all physicians were asked whether they had ever heard or seen Māori patients or whānau (ie, extended family) treated badly or treated less well than Pākehā (ie, individuals of European ethnicity) patients or family during direct interactions (ie, while patients or their whānau are present) or behind their backs (ie, while patients or their whānau are not present).Response options were yes, no, and do not know.

Leaving Medicine
Participants were asked if they had ever considered leaving medicine (Māori physicians) or ever considered dropping out of medicine (Māori medical students).Response categories were yes or no.
A second question asked if they had ever considered taking a break from medicine because of racism,

Results
The ) and were categorized as junior for analysis.A total of 62 physicians (31.2%) indicated they were registrars and a further 56 physicians (28.1%) were specialists in their main current work role.0][31] Distribution by medical school was similar, but our study had a higher proportion of fourth-year students and a lower proportion of sixth-year students compared with all Māori medical students in 2021.Compared with the overall Māori medical workforce, the mean age of physicians in our study was similar (39.4 vs 39.0 years).
Our respondents were more likely to be registrars and specialists as their main work role and less likely to be general practitioners, house officers, and medical officers. 31nsidering leaving medicine was common, reported by 102 Māori physicians (61.8%) and 86 Māori medical students (48.0%  4).

Discussion
3][34] Racism was experienced directly or witnessed by almost all Māori medical students and physicians in our study.In contrast to other studies, we specifically asked questions about racism separate from discrimination, in line with our theoretical approach that conceptualizes racism as a primary experience for Indigenous peoples and an organizing feature of exposure to oppressive systems, harmful environments, and mistreatment at an individual level.The high prevalence of exposure to racism for both time periods examined, and across the continuum of medical education, training, and  witnessing racism in the last 12 months, higher than the national response in the same survey (6% and 13%, respectively). 14evalence of discrimination, bullying, and harassment ever and in the last year was also consistently high for Māori physicians in our study and higher than other studies of Australian and New Zealand physicians.For example, Māori physicians in our study reported direct exposure to discrimination (45.2%), bullying (35.7%), and harassment (20.8%) in the last year.In comparison, a 2016 study of Australasian intensive care medicine fellows and trainees reported a prevalence of 32% for bullying and 12% for discrimination in the 12 months prior. 21A recent study of senior medical officers in New Zealand reported 37.2% experienced bullying in the last 6 months. 35The finding that Māori medical students and physicians report not only high exposure to racism, but also the same or higher prevalence of other forms of discrimination is consistent with research in New Zealand on multiple forms of discrimination. 36tnessed experiences also can have an impact on medical students and physicians and contribute to harmful learning and working environments.Students and physicians reported hearing negative comments and jokes about groups of people related to weight, ethnicity, gender, and sexuality, and perceived socioeconomic characteristics.Stereotypes about people with disabilities were reported at relatively lower frequencies by both Māori physicians and students.This may reflect actual lower prevalence or the normalization of ableist language in medicine meaning lower reporting. 37,38Exposure to these stereotypes is concerning in terms of the safety of Māori medical students and physicians who are members of these groups, as well as potential impacts on patients and patient care.In addition, most physicians and clinical-year students in this study reported witnessing Māori patients and/or their whānau treated badly or worse than New Zealand European people either directly or behind their backs.
High proportions of Māori medical students (48%) and physicians (62%) had considered leaving medicine in our study.While there are not directly comparable measures, this is higher than the 18% of senior physicians and dentists in New Zealand who reported they intended to leave in the next 5 years. 39portantly, one-quarter of Māori medical students and more than one-third of physicians had thought about or taken a break from medicine specifically because of racism, bullying, discrimination, or harassment.This is likely to be an underestimate, as those students or physicians currently on a break or who have left medicine would not have been eligible to take part in our survey.A recent survey with British medical students and physicians found that 23% of physicians had considered leaving and 9% had left medicine because of racial discrimination, 40 and research in the US has shown that physicians who experience workplace discrimination are more likely to consider leaving medicine. 41e impact of racism, discrimination, bullying, and harassment on workforce retention is an underrecognized and underaddressed issue in terms of current health care workforce shortages.
However, it is important to highlight that regardless of whether these exposures impacted negatively on medical students, physicians, or on patients, they are unacceptable.Māori medical students and physicians have a right to learn, train, and work in environments that are free from oppression.
A strength of this study is its wider focus in assessing direct and witnessed experiences, and the broader environment.It likely still understates these exposures, as we asked about experiences ever and in the last 12 months, but not the frequency of these experiences; therefore we did not capture multiple exposures.However, we did include a separate module focused on measuring experiences of everyday racism, including perpetrators and settings, which will be reported in a separate publication.A further strength is the specific focus on Māori, taking into account the particular racialized, colonial contexts for Māori medical students and physicians.Our estimated response rates indicate that the survey included more than 40% of all Māori medical students and approximately one-quarter of all Māori physicians in 2021.Other studies in this area have generally not separated information out for Māori (or Indigenous) medical students and physicians or grouped all New Zealand respondents together with Australian respondents.In addition, the national nature of this survey that includes both medical students and physicians means it captured the experiences across the continuum of medicine.

Limitations
This study has some limitations.As a survey, there may be selection bias in those who chose to participate.This could plausibly include a stronger propensity to respond among those with more experience of the exposures studied or who identify more strongly as Māori.While response rates were reasonably high by modern standards, the reported results should be considered as upper bounds for the prevalence of these exposures.Additionally, in interpreting the study findings, we recognize that the COVID-19 pandemic may have impacted some of the responses to questions about the last 12 months or for people who had joined medical school during the pandemic (eg, more online teaching, less clinical exposure), and that this may have changed the patterning of responses for some of the exposures.

Conclusions
This cross-sectional study found that Māori medical students and physicians are not currently able to train and work in safe environments.These findings require an urgent and systematic response from medical schools and workplaces to ensure that medicine is safe for Indigenous medical students, physicians, and communities.

Figure .
Figure.Racism in the Last Year by Characteristics of Māori Medical Students and Physicians

Table 1 .
Characteristics of Māori Medical Students and Physicians in Survey (last 12 months) are reported in Table 2.In the last year, most Māori medical students ). One-quarter of students (45 students [25.1%] had considered taking a break, because of racism, discrimination, bullying, or harassment in medical school or training, including 33 students (18.4%) who had not taken a break and 12 students (6.7%) who had taken a break; 61 physicians (37.0%) considered taking a break because of racism, discrimination, bullying, or harassment in training or work environments, including 42 physicians (25.5%) who had not taken a break and 19 physicians (11.5%) who had taken a break.Most Māori medical students had directly experienced (131 students [65.2%]) or witnessed (173 students [86.1%]) racism ever in their medical education (Table 2).For Māori physicians, 137 (70.6%) had experienced direct and 173 (89.2%) had witnessed racism in their workplaces or during workrelated activities.Ever experiencing discrimination was also commonly reported for both students (119 students [58.3%] with direct experience and 169 students [82.4%] witnessed) and physicians (133 physicians [67.5%] with direct experience and 177 physicians [88.5%] witnessed).bParticipants were asked, in addition to being Māori, if they identified with belonging to any other groups traditionally marginalized or underrepresented in medicine.cIncludes medical officer and other.experiences

Table 3 )
. Hearing jokes or negative comments about people with disabilities, while lower, was still reported by 49 medical students (24.9%) and 49 physicians (26.1%) (Table3).Among 116 students and 190 physicians who responded to the question, reports for witnessing racism toward Māori patients and their whānau while patients or whānau were present and while they were not present were similar for students in their clinical years (67 students [57.8%] witnessed racism when patients or whānau were present; 87 students [75.0%] witnessed racism when patients or whānau were not present) and physicians (112 physicians [58.9%] witnessed racism when patients or whānau were present; 138 physicians [72.6%] when patients or whānau were not present) (Table3).Women reported higher prevalence of discrimination, racism, bullying (physicians only), and harassment (physicians only) for any direct or witnessed mistreatment in the last year compared with men (Table4).This difference was statistically significant for any racism for medical students (86.8% [95% CI, 80.0%-91.5%] of women vs 58.3% [95% CI, 45.7%-69.9%] of men)(Figure).Except for

Table 2 .
Frequency of Direct and Witnessed Discrimination, Racism, Bullying, and Harassment for Students and Physicians, by Time Period , exposure was higher in the older age groups for students, with a statistically significant association for bullying (age <25 years, 44.0% [95% CI, 36.0%-52.2%]vs age Ն30 years, 84.6% [95% CI, 57.8%-95.7%]).In contrast, younger physicians generally reported the highest exposures, with the exception of harassment.Having at least 1 other marginalized status was associated with Abbreviation: NR, not reported to avoid overreporting at the composite level.a The questions about bullying and harassment were asked later in the survey and have a lower denominator as some people had dropped out of the survey by this point.harassment

Table 3 .
Exposures to Stereotypes and Witnessed Racism Toward Māori Among Māori Medical Students and Māori Physicians

Table 4 .
Racism, Discrimination, Bullying and Harassment in Last Year by Characteristics of Māori Medical Students and Physicians

Table 4 .
Racism, Discrimination, Bullying and Harassment in Last Year by Characteristics of Māori Medical Students and Physicians (continued) Participants were asked, in addition to being Māori, if they identified with belonging to any other groups traditionally marginalized or underrepresented in medicine.Downloaded from jamanetwork.comby guest on 07/04/2024 work, highlights the persistent, ubiquitous nature of racism for Indigenous medical students and physicians.This aligns with a recent Australian study that reported high prevalence of racism for Aboriginal and Torres Strait Islander medical trainees, with 20% directly experiencing and 30% b cIncludes medical officer and other.